https://doi.org/10.3889/oamjms.2022.9359 eISSN: 1857-9655
Category: F - Review Articles Section: Meta-analytic Review Article
The Effect of Vitamin D Deficiency with Stunting and Overweight:
A Meta-analysis Study
Isnani Nurhayati1*, Anas Rahmad Hidayat2, Aris Widiyanto1, Santy Irene Putri3, Joko Tri Atmojo4, Asruria Sani Fajriah5
1Sekolah Tinggi Ilmu Kesehatan Mamba’ul Ulum Surakarta, Surakarta, Indonesia; 2Politeknik Kesehatan Permata Indonesia Yogyakarta, Yogyakarta, Indonesia; 3Midwifery Study Program, Universitas Tribhuwana Tunggadewi Malang, Malang, Indonesia; 4Masters Program in Public Health, Universitas Sebelas Maret, Surakarta, Indonesia; 5Midwifery Study Program, Institut Ilmu Kesehatan STRADA, Kediri, East Java, Indonesia
Abstract
BACKGROUND: Childhood malnutrition, such as stunting and obesity, is an international public health issue leading to an increase in mortality and morbidity risk. Vitamin D deficiency has also been identified as a worldwide public health matter associated with the rise of related-chronic disease prevalence.
AIM: This study aimed to investigate the effect of Vitamin D deficiency with stunting and overweight in children.
METHODS: It was a systematic review and meta-analysis study that used articles from an online database of PubMed, which was published from 2011 to 2021. It employed stunting and overweight as the dependent variables and Vitamin D deficiency as the independent one. The data were analyzed using RevMan.
RESULTS: Subjects with below-standard Vitamin D levels in the body incured 1.86 higher risk of stunting (OR = 1.86; 95% CI 0.90–3.84; p = 0.09) and 2.76 higher risk of being overweight (OR = 2.76; 95% CI 0.96–7.99; p = 0.09) compared with those with normal Vitamin D levels. This result was not statistically significant.
CONCLUSION: Vitamin D deficiency is closely related to stunting and overweight among children under 18 years.
Edited by: Eli Djulejic Citation: Nurhayati I, Hidayat AR, Widiyanto A, Putri SI, Atmojo JT, Fajriah AS. The Effect of Vitamin D Deficiency with Stunting and Overweight: A Meta-analysis Study.
Open Access Maced J Med Sci. 2022 May 07; 10(F):391-396.
https://doi.org/10.3889/oamjms.2022.9359 Keywords: Vitamin D deficiency; Stunting; Overweight
*Correspondence: Isnani Nurhayati, Sekolah Tinggi Ilmu Kesehatan Mamba’ul Ulum Surakarta, Surakarta, Indonesia. E-mail: [email protected] Received: 29-Mar-2022 Revised: 04-Apr-2022 Accepted: 27-Apr-2022 Copyright: © 2022 Isnani Nurhayati, Anas Rahmad Hidayat, Aris Widiyanto, Santy Irene Putri, Joko Tri Atmojo, Asruria Sani Fajriah Funding: This research did not receive any financial support Competing Interests: The authors have declared that no competing interests exist Open Access: This is an open-access article distributed under the terms of the Creative Commons Attribution- NonCommercial 4.0 International License (CC BY-NC 4.0)
Introduction
Overweight and obesity in childhood and adolescence are international public health issues leading to an increased risk of obesity in adulthood, which finally brings about an increase in mortality and morbidity risk due to diseases associated with overweight and obesity [1].
In addition to overweight and obesity, the incidence of malnutrition associated with complications in children’s growth problems is stunting. Stunting is also a public health problem with a particular worldwide concern [2]. It refers to the condition with a relatively low height according to the common age standard [3]. Stunting settings are native to increased susceptibility to infection, impaired brain development, and low IQ in children, and an increase in the risk of obesity and metabolic syndrome in adulthood [4], [5], [6].
Vitamin D deficiency cases among adults and children have been increasingly reported in several regions of the world [7], [8], [9], [10], [11], [12]. An
issue of Vitamin D deficiency in children is a special concern because it inhibits children’s needs to grow and develop [13], [14]. Children require higher calcium than adults do; they need calcium balance to ensure an adequate supply of calcium for the mineralization of growing bones [15], [16]. Limited data and information regarding the relationship of Vitamin D deficiency with nutritional status problems, especially stunting and overweight, underlie the current study.
Methods
Study design
The design of this study is a systematic review and meta-analysis.
Inclusion criteria
This study involved articles published from 2010 to 2021 in the PubMed online database. To
Since 2002
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search the related articles, the researchers input the keywords “Vitamin D deficiency,” “stunting,”
“overweight,” and “children.” The inclusion criteria of this study were: (1) Articles describing the relation of Vitamin D deficiency with stunting or overweight;
(2) original research papers; (3) subjecting children aged 0–18 years; and (4) adopting multivariate logistic regression analysis method. The exclusion criteria for this study were: (1) Articles not in English or Indonesian; (2) review papers; and (3) incomplete or unavailable research data.
Study variables
The dependent variables are stunting and overweight and the independent one is Vitamin D deficiency.
Operational definition
Vitamin D deficiency refers to the condition where a serum 25-OH D3 level in the body is below
<50 nmol/l (<20 ng/ml).
Stunting is defined as a state of chronic malnutrition caused by a relatively-long time lack of nutritional intake resulting in growth disorders in children. The WHO categorizes stunting as a condition that is height per age <1 standard deviation (SD) from the WHO Child Growth Standards median (WHO, 2013).
Being overweight is defined as a condition of excessive accumulation of body fat. In children and adolescents, overweight is identified by a body mass index (BMI) or waist circumference that exceeds the normal standard.
Study instruments
The process of searching and filtering the articles used the PRISMA diagram (Figure 1). The articles should have met the inclusion criteria and have been reviewed using a critical appraisal by the research design of the article.
Results
Subject characteristics
There were a total of 166 articles found from the PubMed online database using the keywords
“Vitamin D deficiency,” “stunting,” “overweight,” and
“children” published between 2011 and 2021. Based on the inclusion criteria and process in qualitative and quantitative synthesis, a total of six articles – four of which were about overweight and the remaining two were about stunting – were collected. The characteristics of each article included in the qualitative synthesis are described in Table 1. Extracted data for each article are shown in Table 2. The number of references and journal sources is available in Table 3. There are two independent variables analyzed using the review manager application 5.3.
The relationship between Vitamin D deficiency and stunting
There were 2 studies included in this analysis [17], [18]. Based on the forest plot (Figure 2), subjects with serum 25-OH D3 levels below the normal standard in the body pose a stunting risk of 1.86 compared to the subjects with normal serum 25-OH D3 levels in the body.
This result proves statistically insignificant (p = 0.09). The heterogeneity of the article (I2) shows the figure of 81%, so the authors use random effect data for the analysis result.
The publication bias shown in the funnel plot chart (Figure 3) cannot be interpreted because it only subjects two articles.
Figure 2: Forest plot of stunting variable Articles identified from
databases (n = 166)
Records after duplicate articles are removed (n = 0)
Articles assessed for eligibility (n = 6)
Articles included (n = 6)
duplicate articles (n = 0)
Articles excluded (n = 160)
IncludedEligibilityScreeningIdentification
Figure 1: The PRISMA flow chart
The relationship between Vitamin D deficiency and overweight
There were 4 studies included in this analysis [19], [20], [21], [22]. Based on the forest plot (Figure 4), subjects with 25-OH D3 serum levels below the normal standard in the body incure a risk of being overweight by 2.76 compared to those with normal 25-OH D3 serum levels. This result is not statistically significant
(p = 0.06). The heterogeneity of the article (I2) shows the figure of 91%, so the authors employ random effect data for the analysis result.
The funnel plot chart (Figure 5) shows a publication bias in the analysis results due to the asymmetrical location of the circle.
Discussion
The meta-analysis result in this study indicates a close relationship between the amount of Vitamin D (measured by levels of 25-OH D3) in the body and the incidence of stunting and overweight.
Vitamin D deficiency with stunting
This study suggest that vitamin D levels affect the incidence of stunting. Subjects with a level of 25-Hydroxyvitamin D3 (25-OH D3) <50 nmol/l are more susceptible to stunting compared to those with a level of 25-OH D3 >50 nmol/l.
Table 1: Characteristic study included
No Author (year) Title Country Study Design Subject Outcome
1 Sharif et al. (2020) Association of vitamin D, retinol and zinc deficiencies with stunting in toddlers: findings from a national study in Iran
Iran Cross-sectional Kids (10-36 month) Although serum 25(OH) D3 levels were not significantly associated with stunting in the overall study population, we found a positive association among toddlers who used nutritional supplements.
2 Mokhtar et al. (2018) Vitamin D status is associated with underweight and stunting in children aged 6-36 months residing in the Ecuadorian Andes
Ecuadorian
Andes Cross-sectional Kids (10-36 month) After adjusting for age and sex, children with 25(OH) D concentration<42·5 nmol/l were more likely to be stunted than children with higher serum concentration.
3 Sharif et al. (2019) Serum Levels of Vitamin D, Retinol and Zinc in Relation to overweight among Toddlers: Findings from a National Study in Iran
Iran Cross-sectional Kids (15-23 month) a marginally significant inverse association was found between serum levels of 25(OH) D3 and overweight
4 Flores et al. (2017) Vitamin D deficiency is common and is associated
with overweight in Mexican children aged 1–11 years
Mexico Cross-sectional Kids (1-11 years) Overweight/obese school-age children had a higher risk of vitamin D deficiency compared with normal-weight children
5 Wakayo et al. (2016) Vitamin D Deficiency is Associated with Overweight and/or Obesity among Schoolchildren in Central Ethiopia: A Cross-Sectional Study
Central
Ethiopia Cross-sectional Kids (11-18 month) We concluded that vitamin D deficiency is an independent predictor significantly associated with overweight and/or obesity among schoolchildren from rural and urban settings in Ethiopia.
6 Greene-Finestone et al.
(2017) Overweight and obesity are
associated with lower vitamin D status in Canadian children and adolescents
Canada Cross-sectional Kids (6-17 month) This study confirms the independent association of overweight/obesity to 25-hydroxyvitamin D level and vitamin D status after adjustment for other factor
Figure 3: Funnel plot of stunting variable
Figure 4: Forest plot of overweight variable
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It goes in line with the research suggesting a relationship between Vitamin D status and nutritional status (height per age) [23]. Other studies also explain that children with stunting make a significantly low consumption of Vitamin D [24].
There found differences in the research results that Vitamin D status is not associated with child’s growth delay [25]. The difference may be due to variations in place, method, and research analysis.
Vitamin D is produced from cholesterol in the skin from sunlight. It can also be obtained from food and supplements. It functions for bone growth and health, as well as calcium homeostatic processes [26]. This is what may underlie the mechanism of the influence of Vitamin D deficiency on stunting.
Vitamin D deficiency with overweight This study suggest that there is an effect of Vitamin D levels on the incidence of overweight.
Subjects with levels of 25-OH D3 <50 nmol/l are more prone to overweight compared to those with levels of 25-OH D3 >50 nmol/l.
The problem of Vitamin D deficiency is greater in children in the overweight BMI category compared to the normal ones [27]. Correspondingly, another study suggests that children with overweight/obese BMI are more susceptible to Vitamin D deficiency as indicated by low levels of 25-OH D3 in the body [28].
Vitamin D deficiency might bring about overweight due to the close relationship between low Vitamin D levels and metabolic syndrome (elevated blood pressure, weak buildup in the body, elevated blood sugar, cholesterol, and triglyceride levels) [29].
Based on in vitro experiments and animal examination, a research explains that the use of Vitamin D affects other tissues in the body, including the pancreas [30].
This affects the homeostatic process of glucose and fat,
resulting in a mechanism that explains how vitamin D contributes to overweight or obesity [30], [31], [32].
Conclusion
The study concludes that there is a relationship between the problem of Vitamin D deficiency in the body with stunting and being overweight. Although the result is insignificant, there indicated a potential for publication bias in the overweight variable. The evaluation of the eligibility of the identified studies was based on predefined criteria and done independently by the six researchers, who examined in detail the quality of those studies. This study highlighted the factors that we need to consider while developing health promotion activities. Further, health literacy, counseling and education program need to be develop in both clinical and community settings.
References
1. Jiang XX, Hardy LL, Baur LA, Ding D, Wang L, Shi HJ. High prevalence of overweight and obesity among inner city Chinese children in Shanghai, 2011. Ann Hum Biol. 2014;41(5):469-72.
Figure 5: Funnel plot of overweight variable Table 2: Data extraction from study included
No Dependent
Variable Study AOR 95% CI Sample size Vitamin D (level
serum 25(OH) D3) Adjusted Factor With
1 Stunting Sharif et al. (2020) 1.33 0.98-1.82 4261 <10 ng/mL sex and residential area, age, family size, first-rank birth, birth interval with previous child, birth-weight, history of diseases (diarrhoea, respiratory infection, fever, epitaxy and fauvism), supplement use (vitamin A, vitamin D, iron and zinc supplements), as well as serum levels of retinol, 25(OH) D3 and zinc
Mokhtar et al. (2018) 2.8 1.6-4.7 516 ≥42.5 nmol/l age (dichotomous) and sex
2 Overweight Sharif et al. (2019) 0.79 0.63–0.99 4261 <10 ng/mL age, family size, first-rank birth, age difference with pre-child, birth weight, history of diseases (diarrhea, respiratory infection, fever, epistaxia and fauvism) Flores et al. (2017) 2.23 1.36-3.66 2695 <50 nmol/l (<20 ng/ml) BMI Z-score, age, gender, area, region, ethnicity, socio-economic status, energy and vitamin D intake Wakayo et al. (2016) 4.59 1.11-18.91 174 <50 nmol/L age groups, vitamin D status and socioeconomic status
Greene-Finestone et al. (2017) 2.63 1.34-5.18 1755 <40 nmol/L -
Table 3: Journal from study included
No Journal source Quantity
1 Public Health Nutrition 2
2 Paediatrics and Child Health (Canada) 1
3 Public Health 1
4 Archives of Iranian Medicine 1
5 Nutrients 1
https://doi.org/10.3109/03014460.2014.910270 PMid:24827735
2. Adair LS. Long-term consequences of nutrition and growth in early childhood and possible preventive interventions.
Nestle Nutr Inst Workshop Ser. 2014;78:111-20. https://doi.
org/10.1159/000354949 PMid:24504211
3. Dabbagh-Moghadam A, Mozaffari-Khosravi H, Nasiri M, Miri A, Rahdar M, Sadeghi O. Association of white and red meat consumption with general and abdominal obesity: A cross- sectional study among a population of Iranian military families in 2016. Eat Weight Disord. 2017;22(4):717-24. https://doi.
org/10.1007/s40519-017-0385-x PMid:28421475
4. DeBoer MD, Lima AA, Oría RB, Scharf RJ, Moore SR, Luna MA, et al. Early childhood growth failure and the developmental origins of adult disease: Do enteric infections and malnutrition increase risk for the metabolic syndrome? Nutr Rev. 2012;70(11):642-53.
https://doi.org/10.1111/j.1753-4887.2012.00543.x PMid:23110643
5. Dewey KG, Begum K. Long-term consequences of stunting in early life. Matern Child Nutr. 2011;7 Suppl 3:5-18. https://doi.
org/10.1111/j.1740-8709.2011.00349.x PMid:21929633
6. Perumal N, Bassani DG, Roth DE. Use and misuse of stunting as a measure of child health. J Nutr. 2018;148(3):311-5. https://
doi.org/10.1093/jn/nxx064 PMid:29546307
7. Hilger J, Friedel A, Herr R, Rausch T, Roos F, Wahl DA, et al. A systematic review of Vitamin D status in populations worldwide. Br J Nutr. 2014;111(1):23-45. https://doi.org/10.1017/
S0007114513001840 PMid:23930771
8. Holick MF, Chen TC. Vitamin D deficiency: A worldwide problem with health consequences. Am J Clin Nutr. 2008;87(4):1080S-6S.
https://doi.org/10.1093/ajcn/87.4.1080S PMid:18400738
9. Lips P. Worldwide status of Vitamin D nutrition. J Steroid Biochem Mol Biol. 2010;121(1-2):297-300. https://doi.org/10.1016/j.
jsbmb.2010.02.021 PMid:20197091
10. Mithal A, Wahl DA, Bonjour JP, Burckhardt P, Dawson-Hughes B, Eisman JA, et al. Global Vitamin D status and determinants of hypovitaminosis D. Osteoporos Int. 2009;20(11):1807-20.
https://doi.org/10.1007/s00198-009-0954-6 PMid:19543765
11. Palacios C, Gonzalez L. Is Vitamin D deficiency a major global public health problem? J Steroid Biochem Mol Biol. 2014;144 Pt A:138-45. https://doi.org/10.1016/j.jsbmb.2013.11.003
PMid:24239505
12. van Schoor NM, Lips P. Worldwide Vitamin D status. Best Pract Res Clin Endocrinol Metab. 2011;25(4):671-80. https://doi.
org/10.1016/j.beem.2011.06.007 PMid:21872807
13. Bachrach LK. Acquisition of optimal bone mass in childhood and adolescence. Trends Endocrinol Metab. 2001;12(1):22-8.
https://doi.org/10.1016/s1043-2760(00)00336-2 PMid:11137037
14. Rauch F. Bone accrual in children: Adding substance to surfaces. Pediatrics. 2007;119 Suppl 2:S137-40. https://doi.
org/10.1542/peds.2006-2023E PMid:17332233
15. Shin YH, Shin HJ, Lee YJ. Vitamin D status and childhood health. Korean J Pediatr. 2013;56(10):417-23. https://doi.
org/10.1542/peds.2006-2023E PMid:17332233
16. WHO. Global Nutrition Policy Review: What Does It Take to Scale Up Nutrition Action? Geneva, Switzerland: World Health Organization; 2013.
17. Sharif Y, Sadeghi O, Dorosty A, Siassi F, Jalali M, Djazayery A, et al. Association of Vitamin D, retinol and zinc deficiencies with stunting in toddlers: Findings from a national study in Iran. Public Health. 2020;181:1-7. https://doi.org/10.1016/j.
puhe.2019.10.029 PMid:31887436
18. Mokhtar RR, Holick MF, Sempértegui F, Griffiths JK, Estrella B, Moore LL, et al. Vitamin D status is associated with underweight and stunting in children aged 6-36 months residing in the Ecuadorian Andes. Public Health Nutr. 2018;21(11):1974-85.
https://doi.org/10.1017/S1368980017002816 PMid:29162164
19. Sharif Y, Sadeghi O, Dorosty A, Siassi F, Jalali M, Djazayery A, et al. Serum levels of Vitamin D, retinol and zinc in relation to overweight among toddlers: Findings from a national study in Iran. Arch Iran Med. 2019;22(4):174-81.
PMid:31126175
20. Flores A, Flores M, Macias N, Hernández-Barrera L, Rivera M, Contreras A, et al. Vitamin D deficiency is common and is associated with overweight in Mexican children aged 1-11 years. Public Health Nutr. 2017;20(10):1807-15. https://
doi.org/10.1017/S1368980017000040 PMid:28241892
21. Wakayo T, Whiting SJ, Belachew T. Vitamin D deficiency is associated with overweight and/or obesity among schoolchildren in central ethiopia: A cross-sectional study.
Nutrients. 2016;8(4):190. https://doi.org/10.3390/nu8040190 PMid:27043619
22. Greene-Finestone LS, Garriguet D, Brooks S, Langlois K, Whiting SJ. Overweight and obesity are associated with lower Vitamin D status in Canadian children and adolescents. Paediatr Child Health. 2017;22(8):438-44. https://doi.org/10.1093/pch/pxx116 PMid:29479261
23. Marasinghe E, Chackrewarthy S, Abeysena C, Rajindrajith S.
Micronutrient status and its relationship with nutritional status in preschool children in urban Sri Lanka. Asia Pac J Clin Nutr.
2015;24(1):144-51. https://doi.org/10.6133/apjcn.2015.24.1.17 PMid:25740753
24. van Stuijvenberg ME, Nel J, Schoeman SE, Lombard CJ, du Plessis LM, Dhansay MA. Low intake of calcium and Vitamin D, but not zinc, iron or Vitamin A, is associated with stunting in 2- to 5-year-old children. Nutrition. 2015;31(6):841-6. https://doi.
org/10.1016/j.nut.2014.12.011 PMid:25933491
25. Chowdhury R, Taneja S, Bhandari N, Kvestad I, Strand TA, Bhan MK. Vitamin-D status and neurodevelopment and growth in young north Indian children: A secondary data analysis. Nutr J. 2017;16(1):59. https://doi.org/10.1186/s12937-017-0285-y PMid:28923060
26. Rafraf M, Hasanabad SK, Jafarabadi MA. Vitamin D status and its relationship with metabolic syndrome risk factors among adolescent girls in Boukan, Iran. Public Health Nutr.
2014;17(4):803-9. https://doi.org/10.1017/S1368980013003340 PMid:24477119
27. Turer CB, Lin H, Flores G. Prevalence of Vitamin D deficiency among overweight and obese US children. Pediatrics.
2013;131(1):e152-61. https://doi.org/10.1542/peds.2012-1711 PMid:23266927
28. Au LE, Rogers GT, Harris SS, Dwyer JT, Jacques PF, Sacheck JM.
Associations of Vitamin D intake with 25-hydroxyvitamin D in
396 https://oamjms.eu/index.php/mjms/index overweight and racially/ethnically diverse US children. J Acad
Nutr Diet. 2013;113(11):1511-6. https://doi.org/10.1016/j.
jand.2013.05.025 PMid:23916971
29. Lee SH, Kim SM, Park HS, Choi KM, Cho GJ, Ko BJ, et al. Serum 25-hydroxyvitamin D levels, obesity and the metabolic syndrome among Korean children. Nutr Metab Cardiovasc Dis. 2013;23(8):785-91. https://doi.org/10.1016/j.
numecd.2012.04.013 PMid:22762845
30. Delvin EE, Lambert M, Levy E, O’Loughlin J, Mark S, Gray- Donald K, et al. Vitamin D status is modestly associated with glycemia and indicators of lipid metabolism in French-Canadian
children and adolescents. J Nutr. 2010;140(5):987-91. https://
doi.org/10.3945/jn.109.112250 PMid:20237070
31. Reis JP, von Mühlen D, Miller ER 3rd, Michos ED, Appel LJ.
Vitamin D status and cardiometabolic risk factors in the United States adolescent population. Pediatrics. 2009;124(3):e371-9.
https://doi.org/10.1542/peds.2009-0213 PMid:19661053
32. Mitri J, Nelson J, Ruthazer R, Garganta C, Nathan DM, Hu FB, et al.
Plasma 25-hydroxyvitamin D and risk of metabolic syndrome: An ancillary analysis in the Diabetes Prevention Program. Eur J Clin Nutr. 2014;68(3):376-83. https://doi.org/10.1038/ejcn.2013.293 PMid:24448494
